JAMA 26 Jan 2011 Vol 305
391 Stroke medicine grew up in the 1990s: like heart failure medicine, it shone welcome light on a large and neglected group of patients with organ damage who had been written off as unsalvageable. This was a Very Good Thing in itself, but its proponents then went on to declare that good stroke care could only be provided in designated stroke units, and went on to run some not-very-randomised trials to prove it. They also began to talk up the evidence for the benefits of immediate thrombolysis, which are real but extremely modest. These fashions spread to the USA following recommendations of the Brain Attack Commission in 2000, and this study evaluates the effect in New York State in 2005-6, comparing mortality and the use of thrombolysis in 31,000 patients with stroke, equally divided between hospitals with or without stroke units. There was a large difference in thrombolysis use - 4.8% in stroke units, versus 1.7% elsewhere; but a very small difference in mortality at 30 days - 10.7% versus 12.5%. It would be nice if someone could go on to look at a wider range of patient-important outcomes too.
NEJM 27 Jan 2011 Vol 364
303 One of the nightmare jobs you are glad someone else does is finding veins in haemodialysis patients. Someone who does this from time to time will be very glad to read this study showing that recombinant tissue plasminogen activator is twice as good as heparin at keeping central venous lines open and three times as good at preventing bacteraemia. Luck will be needed to get hospital trust to meet the extra cost.
http://www.nejm.org/doi/full/10.1056/NEJMoa1011376
313 The New England Journal allows you free access to this paper on Ventricular Tachyarrhythmias after Cardiac Arrest in Public versus at Home and in case you are inclined to spurn this generous offer, take a look at these excerpts from the editorial about it by Gust H Bardy M.D.:
If CPR were a drug or a surgical procedure, its value would be tested prospectively, but it has not been. Could it be that innovation in the field is hampered by a reluctance to let go of an entrenched approach that has only the appearance of value?
Knowledge of the absolute measured value of CPR would have a profound influence on the direction of research on sudden cardiac arrest and the conservation of resources. More than 40 years after its inception, CPR has never been compared with no CPR in a randomized trial involving patients with sudden cardiac arrest. Although not performing CPR is a heretical idea, it is not unethical; clinical equipoise does exist for the comparison of chest compression with no compression.
Click the links and read on
http://www.nejm.org/doi/full/10.1056/NEJMoa1010663
http://www.nejm.org/doi/full/10.1056/NEJMe1012554
351 Chronic thromboembolic pulmonary hypertension sounds nasty and almost bound to be underdiagnosed, and indeed it is both. It is fairly easy to spot when it follows acute pulmonary embolism as it does in 2-4% of PEs. But we simply don't know how often it occurs without overt PE, because much of it may lie hidden as "idiopathic" pulmonary hypertension and not present until right heart failure has set in. By which time it is a bit late: the "heroic" treatment is surgical: "Pulmonary thromboendarterectomy is performed with the use of cardiopulmonary bypass with intermittent circulatory arrest to permit dissection from the main pulmonary arteries to the subsegmental branches." Not surprisingly, it doesn't always work, and many patients are too sick to have it done.
http://www.nejm.org/doi/full/10.1056/NEJMra0910203
Lancet 29 Jan 2011 Vol 377
393 Eltrombopag! Eltrombopag! O keep it in your doctor's bag! was sang when first encountered this orally available thrombopoeitin receptor agonist. It makes you make platelets and so reverses chronic immune thrombocytopenia - as long as you keep taking the tablets. The Lancet has decided to print the RAISE study as it first appeared on their website, despite some second thoughts by its authors - if you like this kind of thing, it's all explained in an editorial by Lancet house staff on p.360. Apparently they made some claims about the inferiority of eltrombopag's main competitor drug, romiplostim, which may not be sustainable. Plus failing to mention that their patients were splenectomised. Naughtiness.Eltrombopag! Eltrombopag! Doctor will keep it in his bag,Depending on what it might cost him -He might just plump for romiplostim.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60959-2/abstract
BMJ 29 Jan 2011 Vol 342
275 And of course I have to declare an interest in the Easily Missed series, which I helped to set up. I think I may even have suggested Joint Hypermobility Syndrome and I'm certainly glad that it produced such a good contribution, well illustrated and a bit longer than most. Please let's have your further submissions to keep this series going indefinitely - after all, there's no end to what you can miss in medicine. But don't be surprised if we keep your article short and down to ten references.
http://www.bmj.com/content/342/bmj.c7167.extract
Arch Intern Med 24 Jan 2011 Vol 171
134 A drug that produces a 41% reduction in recurrent cardiovascular events following myocardial infarction - now wouldn't that get some marketing! The only drug that comes near that is alcohol - which does get a lot of marketing, but not for that reason. Here there is no drug at all: just talking. Mind you, quite a lot of talking, in the form of 20 two-hour sessions of traditional cognitive behavioural therapy in the first year after MI. Now let's say this was a new antiplatelet drug produced by pharma, and sold at £115 per month (a generous estimate of the cost of the CBT): every post-infarct patient would be clamouring for it to be funded by the NHS. But it's only CBT, which is also the best treatment for lots of other things. So forget about ever being able to get it.
http://archinte.ama-assn.org/cgi/content/abstract/171/2/134
No comments:
Post a Comment